Cosmetic dermatologists have never before had so
many unique options for facial rejuvenation.
From topical creams to fractional ablative resurfacing,
supplemented by an incredible range of
interventions from injectables to minimally-invasive
devices, the practitioner now chooses from a wide
range of never before available treatments. It is from
this middle of the pack that most patients will receive
one or a combination of treatments. Deciding what
interventions to offer and how to combine treatments
can be a challenge and is dependent on the needs of
the specific patient and the resources of the practice.

One of the reasons I started Cosmetic Surgery
Forum two years ago was to afford practitioners the
ability to discourse on all pertinent topics, structured
within a CME environment. All too often, marketing
seminars, with the attendant restriction to 'on-label'
discussions, pervades our learning environments.
Given the fact that most dermatologists and cosmetic
surgeons practice in a completely different manner
than the 'on-label' indications, I felt it was important
to provide an opportunity to discuss these differences
in practice, ranging from the subtle to the extreme.

At the Cosmetic Surgery Forum in Las Vegas in
December, leading cosmetic surgeons shared their
insights on rejuvenation techniques and procedures,
frequently debating amongst themselves, with input
from the audience and panel. Following are reports on
some of the many discussions that occurred during
the second Cosmetic Surgery Forum.

Understand Facial AgingThe secret of success in applying cosmetic facial rejuvenation
techniques lies in understanding the processes
of facial aging, said Gregory A. Buford, MD,
Founder and Medical Director of Beauty by Buford in
Denver. The appearance of facial aging involves the
skin and underlying structures, including bone and
fat, he explained. He described three basic phases of
progression in each domain.

Age-induced changes to the skin typically begin
with pigmentary alterations and the formation of
brown spots and dyschromia. With time, collagen loss
becomes evident, coinciding with the formation of
lines and wrinkles. Finally, overall thinning of the skin
can be seen.

Volume loss to fat pads is the first sign of aging.
This is followed by localized “deflation” that eventually
leads to a flattening of the mid-face.

As an individual ages, changes in bony structures
may produce the appearance either of an increase in
volume in some areas or a loss of it in others.
Eventually, as bone changes take place, the structure
of the face will change, leading to widening of the
jawline and an inversion of the up-side down pyramid
structure of the youthful face.

Given these various changes, the best approach to
rejuvenation has changed recently, now frequently
involving the combined use of lasers/light devices and
injectables, with less emphasis on the face-lift as a
'cure all'. Energy-based devices largely affect the skin,
working to improve pigmentation, smooth lines and
wrinkles, while tightening sagging skin, and to some
degree reducing unwanted fat deposits. However, to
rebalance the structural changes that take place due to
volume loss and bone changes requires the use of dermal
fillers and neurotoxins.

Dr. Buford reported that he frequently uses fractional
CO2 resurfacing (Active/Deep FX, Lumenis) in
combination with the neurotoxins and fillers he feels
are best suited to the patient’s aesthetic needs and
concerns.

Consider Non-invasive “Lifting”Many patients in search of rejuvenation procedures
seek a “lifting” of sagging facial skin. Surgical facelifts
obviously provide such benefit, but they require invasive
surgery, are associated with significant downtime,
are expensive, and often provide a result that is too
dramatic or “artificial.” Therefore, subtle lifting has
emerged as the goal of many clinicians. According to
Curt Samlaska, MD of Academic Dermatology in
Henderson, NV, the only energy-based technology
FDA cleared for non-invasive lift (brow lift, September
2009), is Ulthera, which provides notable but natural-looking
improvements when properly applied.

Ulthera uses micro-focused ultrasound energy to
provide a tissue tightening and lifting effect. Optimal
correction may require several treatments over time.
When patients have reasonable expectations for the
number of treatments and treatment guidelines, response and satisfaction rates are high, Dr. Samlaska
said. Treatment is safe for all skin types with no risk
of pigmentary alteration, based on his data.

The dual modality ultrasound system allows the
operator to visualize structures below the skin’s surface
(to 8mm depth) while precisely delivering energy
that converges at target points, known as “thermal
coagulation points.” Thermal energy is deposited at
these coagulation points, affecting local tissues. The
size and depth of the points depends on the frequency
and power settings selected by the operator.

Use of thermal coagulation points spares designated
areas of tissue to encourage and speed healing.

The Ulthera System has not been evaluated for
application over mechanical implants, dermal fillers,
implanted electrical devices, or metal stents and is not
recommended for use over these materials in the face
and neck area. Additionally, use directly on keloids
has not been studied and should be avoided, Dr.
Samlaska noted.

Optimize Non-ablative TreatmentsSignificant rejuvenation effects are possible with ablative
resurfacing devices, such as CO2 and erbium systems;
however, these devices are associated with significant
downtime and potential adverse events. Nonablative
devices have provided much more modest
results, with the degree of success sometimes linked to
operator skill and patient expectations/education prior
to the procedure. Optimal results and minimal downtime
from non-ablative devices may be possible
through the combined use of nonablative fractionated
lasers (such as Fraxel re:store) and radiofrequency
tightening devices (Thermage), suggested Heidi A.
Waldorf, MD, Director of Laser and Cosmetic
Dermatology and Associate Clinical Professor in the
Department of Dermatology at Mount Sinai Hospital
in New York City who practices at Waldorf
Dermatology & Laser Associates in Nanuet, NY.

Nonablative fractionated lasers—associated with
just two to three days of postoperative swelling and
about five days of peeling—provide resurfacing benefits,
while radiofrequency devices—which have no
downtime—producing tightening. Furthermore, these
devices can be used also to treat the neck, chest, and arms, eliminating any demarcation lines or mismatched
areas of coloration that have been limitations
of ablative devices.

Achieving good cosmetic results and assuring
patient satisfaction depends on setting realistic patient
expectations, Dr. Waldorf said. Nonablative resurfacing
generally does not generate a sufficient effect with
just a single session; multiple treatments are necessary
over time. Furthermore, patients should understand
that radiofrequency tightening is not equivalent to a
surgical facelift. Patients and practitioners, therefore,
should develop a “building plan” at the start of therapy,
Dr. Waldorf says.

“Clean–up” treatments following the combined nonablative
procedures may include a vascular laser to
address erythema or a pigment laser for discreet pigmented
lesions. Fillers and/or neurotoxins can be
included in the treatment regimen to improve specific
areas, and cosmeceuticals should be used to help
maintain effects and continue to improve the appearance
of skin.

Finally, Dr. Waldorf advised all in attendance to
“Know your population” when selecting devices, suggesting
that clinicians must consider what types of
treatments patients may desire, what types of results
they may anticipate, and the degree of downtime
and speed of improvement they may be willing to
tolerate.

Update on Topical Interventions
Two popular topical product ingredients continue to generate interest
among patients and cosmetic dermatologists.
1.) The regulatory status of hydroquinone, the skin lightening drug
formulated into prescription and over-the-counter formulations,
remains uncertain, Jeannette Graf, MD reported. Grandfathered as
safe and effective medication since 1963, the early 1980s saw hydroquinone
concentrations from 0.5-2% classified as “Generally Rated As
Safe and Effective” or GRASE by FDA. However, in 2006 FDA proposed
re-classifying hydroquinone, thus eliminating OTC use in the US.

Hydroquinone was banned in the EU in 2001 due to concerns about the
development of exogenous ochronosis; however, Dr. Graf said, data
show about 30 incidences, not all of which are biopsy proven, of
exogenous ochronosis reported in North America, despite widespread
use of topical hydroquinone. According to Dr. Graf, there are no reports
of human malignancy associated with hydroquinone use while it
was in widespread use in the 1920s by the photographic/film industry.

There are also a few worldwide reports of cutaneous annular sarcoidosis
developing on a background of exogenous ochronosis. Most of
these didn't have biopsy prior to the application of HQ, so it is difficult
to say whether the initial treatment was mistakenly applied to an area
of sarcoidosis or not. Risk of ochronosis is thought to be associated
with prolonged use of topical hydroquinone and is more common in
patients with darker skin types, but there are many contradictions in
reports and it is unclear whether all supposed preparations of HQ are
purely HQ or contain other ingredients/impurities.

2.) Topical retinoids, which have been shown to prevent UV-induced
collagen degradation, continue to be cornerstones of many topical
antiaging regimens. UV exposure incites AP-1 induction, which mediates
the formation of collagenase and gelatinase, Leon Kircik, MD,
explained. Retinoids are shown to block AP-1, thus stopping the UVinduced
degradation process. Currently, four derivatives of vitamin A
are used in prescription and OTC skincare products:

• Retinol. Pure Vitamin A converts in part to tretinoin. It has been
shown to repair photodamage independent of this conversion.
• Retinyl Palmitate. This artificially stabilized Vitamin A must be converted
to retinol to be effective. Despite environmental watchdog
industry concerns about this ingredient in sunscreens, Dr. Kircik feels
it is safe and perhaps a cancer prevention strategy.
• Retinaldehyde. Likely the form of vitamin A that is closest to
tretinoin in conversion process, it has been shown to be as irritating as
tretinoin, though not as effective.
• Tretinoin. The biologically active form of Vitamin A binds to the
nuclear retinoid R and X receptors.

Evidence continues to suggest that the efficacy of retinol, which is not
associated with significant irritation, depends on the influence of the
vehicle formulation on penetration and bioavailability, Dr. Kircik said.
For example, he noted that emulsified retinol has low bioavailability.
Furthermore, ingredients in a formulation may increase irritation. By
contrast, he noted that a novel formulation of retinol in suspension
(Retriderm, Biopelle) offers good bioavailability and incorporates
ingredients intended to reduce transepidermal water loss and to
enhance barrier function and repair. The new formulation has shown
clinical effects similar to prescription tretinoin, he said.

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Practical Dermatology is the monthly publication that provides coverage of medical care, cosmetic advancements, and practice management for clinicians in the field. With straight-forward, how-to advice from experts in various fields, we strive to enhance quality of care and improve the daily operation of dermatology practices.

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